A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression

Controversy exists regarding the benefit of endoscopic carpal tunnel release versus open carpal tunnel release in terms of grip/pinch strength, scar tenderness, pain, return to work, reversible/irreversible nerve damage, and adverse effects. Although a number of randomized controlled trials and systematic reviews have been published on the subject, to date, no large definitive randomized controlled trial or meta-analysis has been performed comparing endoscopic to open carpal tunnel release. This meta-analysis was undertaken to address the effectiveness of endoscopic carpal tunnel release relative to open carpal tunnel release. Key outcome measures from 13 randomized controlled trials were extracted and statistically combined. Heterogeneity was observed in three of the outcomes (i.e., grip strength, pain, and return to work), but the causes of heterogeneity could not be explained because of insufficient detail in the reported studies. Using the Jadad et al. scale, nine of 13 studies were of low methodologic quality. The effect sizes were compared between the studies that were rated as high quality and the studies that were rated as low quality on the Jadad et al. scale. Similarly, the studies that were rated as high quality on the Gerritsen et al. scale were compared with those that were rated as low quality. No clinically significant difference in effect sizes was apparent between studies of high and low methodologic quality. This meta-analysis supports the conclusion that endoscopic carpal tunnel release is favored over the open carpal tunnel release in terms of a reduction in scar tenderness and increase in grip and pinch strength at a 12-week follow-up. With regard to symptom relief and return to work, the data are inconclusive. Irreversible nerve damage is uncommon in either technique; however, there is an increased susceptibility to reversible nerve injury that is three times as likely to occur with endoscopic carpal tunnel release than with open carpal tunnel release.     

A systematic review of reviews comparing the effectiveness of endoscopic and open carpal tunnel decompression

Controversy persists regarding the benefit of endoscopic carpal tunnel release compared with open carpal tunnel release for pain, numbness, strength, return to work and function, scar tenderness, and complications. For surgeons, a recommended first source of information on treatment effectiveness is a review of high-methodologic-quality articles. This review of reviews was undertaken to answer this clinical question regarding these outcomes. Cochrane, MEDLINE, EMBASE, CINAHL, and HealthSTAR databases were searched using the key words "endoscopic carpal tunnel," with limits "review or overview" and dates from 1989 to present. Five key journals were hand-searched. Any review with a reference to at least one randomized controlled trial that compared endoscopic carpal tunnel release to open carpal tunnel release was to be included. Two reviewers independently scanned titles and abstracts for potential relevance. Selection as relevant was confirmed through a review of full texts. Disagreements were resolved through discussion and consensus. The selected reviews were assessed for methodologic quality on the basis of the scale of Hoving et al. Of 48 articles initially identified, seven pertinent reviews were selected. Of these seven, three reviews of high methodologic quality concurred that there is no difference between the two techniques in symptom relief and that the evidence is conflicting for return to work and function. The risk of permanent median nerve injury does not differ between the techniques. The reviews indicated that the endoscopic carpal tunnel release technique is worse in terms of reversible nerve injury but superior in terms of grip strength and scar tenderness, at least in short-term follow-up. Several trials have not been incorporated in these reviews and statistical pooling has not been conducted. Further systematic review with meta-analysis may permit more definitive conclusions about the relative effectiveness of these two techniques, particularly with regard to return to work and function.     

A comparison of flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome

The purpose of this study was to identify the advantages and disadvantages of performing a flexor tenosynovectomy without dividing the transverse carpal ligament, an open carpal tunnel release, and an open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome. From 1990 to 1998, a retrospective study was done in which a flexor tenosynovectomy was performed in 133 patients without division of the transverse carpal ligament and compared with 68 patients who had an open carpal tunnel release and 75 patients who had an open carpal tunnel release and flexor tenosynovectomy. Patients were followed up for an average period of 30 weeks with history and physical findings and nerve conduction velocities and for an average period of 2.6 years with telephone interviews. There was a 2.3 percent incidence of pillar pain in the flexor tenosynovectomy group, which may explain the earlier return to their regular jobs at an average time of 9.9 weeks, compared with 10.7 weeks for the carpal tunnel release group and 12.0 weeks for the carpal tunnel release/flexor tenosynovectomy group. The latter two groups had an incidence of pillar pain of 12.1 percent and 25.3 percent, respectively. Postoperative grip strength was statistically significantly improved in the flexor tenosynovectomy group compared with the other two groups, where adjustments were made for sex and preoperative grip strengths with standard error of adjusted means. In the flexor tenosynovectomy group, 20.6 percent of patients had a previous open or endoscopic carpal tunnel release with recurrent carpal tunnel syndrome, compared with 5.2 percent in the open carpal tunnel release group and 21.6 percent in the open carpal tunnel release with flexor tenosynovectomy group. Excisional biopsies of flexor tenosynovium in the flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy groups revealed an incidence of fibrosis in 89.2 percent, 88.9 percent, and 87.7 percent of specimens, respectively. Edema was a frequent finding, but an active inflammatory response was seldom seen. The findings in this study indicate that because of a significant decrease in pillar pain, a flexor tenosynovectomy in the treatment of carpal tunnel syndrome would likely benefit workers who use the palm of the hand in heavy manual or highly repetitive work by allowing them to return to regular duty sooner.     

CO2激光治疗26例甲真菌病临床观察

目的探讨CO2激光治疗甲真菌病的临床疗效。方法对44例甲真菌病病例共92只病甲采用每2周1次CO2激光烧灼打孔,疗程共24周。结果治疗有效率90%。结论CO2激光治疗甲真菌病安全、有效、副作用小。     

Genetic linkage analysis of the carpal tunnel syndrome

Two generations of a family with autosomal dominant carpal tunnel syndrome were studied for genetic linkage to 20 informative polymorphic blood markers. No linkage was demonstrated between the syndrome and the markers tested; exclusion of close linkage (lod score less than -2.0) was found for MNSs, ACP, GALT, GPT, GLO, Hp, Gc, and Pi.     

CO2激光治疗重度宫颈糜烂

作者用ＣＯ２激光治疗了重度宫颈糜烂２９２例,单纯型２４例,颗粒型１６６例,乳突型１０２例。结果：２８２例获治愈（９６．２％）,其中２４９例（８５．２％）一次性痊愈,１０例好转,无一例无效。说明该疗法简便,迅速,无明显副作用,疗效显著,是治疗重度宫颈糜烂的有效方法。     

Comparison of partial excision with simple section of the transverse carpal ligament in the treatment of carpal tunnel syndrome

In the surgical treatment of carpal tunnel syndrome, debate has commonly focused on whether decompression should be performed by open or blind techniques. Contrarily, the goal of the present study was to determine whether instead of simple section, partial excision of the transverse carpal ligament has contributed to better results. Because complete healing of the transverse carpal ligament observed during reoperations has been reported elsewhere, the charts of 75 carpal tunnel syndrome patients who had been treated with open technique at Dokuz Eylül University were reviewed. Statistical analysis was performed using the Fisher's exact test and Student's t test when appropriate. Thirty-five patients had been treated with simple section of the transverse carpal ligament, whereas 40 had been treated with partial excision. Internal neurolysis was also performed in 19 of the patients, 11 of whom were treated with partial excision. The average follow-up time was 3.8 years. The comparisons regarding the overall operative outcomes did not show any significant difference between the two different techniques of releasing the transverse carpal ligament. In patients treated without neurolysis, results of partial excision of the transverse carpal ligament improved when compared with those of simple section, but this superiority was not statistically significant. There seemed to be statistically higher reoperation rates and worse outcomes after neurolysis (p < 0.05). Reoperation was required in eight patients (11 percent). Five of the patients who underwent reoperation had initially been treated with partial excision and neurolysis, whereas two had been treated with simple section and neurolysis. Another patient who had undergone reoperation had initially undergone only simple section. The mean time to return to work or daily activities did not differ between the types of applied technique for releasing the transverse carpal ligament. However, neurolysis lengthened these periods significantly when performed (p < 0.05). In the present study, partial excision of the transverse carpal ligament without adding neurolysis offered relatively better results than simple section. Verification of this finding endoscopically, if applicable, may improve the success rate of surgical therapy in patients with carpal tunnel syndrome.     

Microsurgical anastomosis of rat carotid arteries with the CO2 laser

In order to further evaluate the role of lasers in microvascular tissue closure, we modified an existing CO2 surgical laser (Xanar XA-20) by adding a partially reflecting mirror to attenuate the beam. This allowed the laser to operate at an output of approximately 100 mW, which was appropriate to achieve microvascular closures. In each of 43 rats, one carotid artery was transected and then anastomosed with standard suture technique with 10 to 12 simple interrupted sutures of size 10-0 Ethilon nylon suture (Ethicon, Inc.). The opposite carotid in each rat was anastomosed by the placement of three stay sutures followed by the application of laser irradiation to the tissue between the stay sutures at 90 to 100 mW, spot size of 0.2 mm, pulse duration 0.2 seconds, approximately 20 to 30 pulses per anastomosis. In vivo test periods were 1 hour, 1 day, 3 days, 7 days, 10 days, 14 days, 28 days, 91 days, and 180 days. All anastomoses were evaluated for patency, and selected samples were utilized for light microscopy, and mechanical testing (intraluminal pressure raised to 300 mmHg). It was determined that similar patency rates and slightly faster time to perform the same procedure could be achieved with the use of the low-powered CO2 laser. However, histologic evidence of significant medial damage raises concern about the long-term risk of a higher aneurysm rate. Vessel damage and the lack of simple intraoperative methods to verify the quality of the laser technique restrict these authors from advocating the clinical introduction of the procedure until further advances are made.(ABSTRACT TRUNCATED AT 250 WORDS)     

Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial

ObjectiveTo assess the effect of a 40 mg methylprednisolone injection proximal to the carpal tunnel in patients with the carpal tunnel syndrome.DesignRandomised double blind placebo controlled trial. SettingOutpatient neurology clinic in a district general hospital.ParticipantsPatients with symptoms of the carpal tunnel syndrome for more than 3 months, confirmed by electrophysiological tests and aged over 18 years.InterventionInjection with 10 mg lignocaine (lidocaine) or 10 mg lignocaine and 40 mg methylprednisolone. Non-responders who had received lignocaine received 40 mg methylprednisolone and 10 mg lignocaine and were followed in an open study.ResultsAt 1 month 6 (20%) of 30 patients in the control group had improved compared with 23 (77%) of 30 patients the intervention group (difference 57% (95% confidence interval 36% to 77%)). After 1 year, 2 of 6 improved patients in the control group did not need a second treatment, compared with 15 of 23 improved patients in the intervention group (difference 43% (23% to 63%). Of the 28 non-responders in the control group, 24 (86%) improved after methylprednisolone. Of these 24 patients, 12 needed surgical treatment within one year.ConclusionA single injection with steroids close to the carpal tunnel may result in long term improvement and should be considered before surgical decompression.

Key messages

• Corticosteroid injections into the carpal tunnel may damage the nerve, and any treatment benefits may be of short duration
• A single injection with steroids proximal to the carpal tunnel improves 77% of patients with the carpal tunnel syndrome at one month after treatment
• This single injection is still effective at one year in half of the patients
• Injections proximal to the carpal tunnel have no side effects and are easier to carry out than injections into the carpal tunnel